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Conduct of Pulmonary Bypass > Conduct of Pulmonary Bypass > Flashcards

Conduct of Pulmonary Bypass Flashcards

1
Q

before even assembling the circuit, what should you do

A
  • review the pt’s chart for proposed surgical procedure and relevant history
  • pt height and weight to determine circuit size and cannula selection
  • surgery and surgeoun determine what kind of disposable components to use
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2
Q

what should you do with disposable equipment

A

check date of expiration, sterility, and package integrity

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3
Q

pull supplies that you will generally need

A 
tubing pack
cardiotomy pack 
oxygenator 
fluids
heparin, syringe, and needle
blood cardioplegia set and fluid
clamps 
paperwork
CDI sensor
ACT machine
I-pad
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4
Q

what are supplies that you will need that are case specific

A
  • arterial cannula: femoral or aortic
  • venous cannula; femoral, SAC, or bi-caval
  • retrograde cardioplegia cannula
  • extra suction tubing
  • “y” and straight connectors
  • biomedicus console
  • redo equipment
  • bridge
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5
Q

assemble circuit

A
  1. confirm sterile packing
  2. assemble circuit
  3. verify proper blood flow diraction from operative field to CPB and back
  4. verify direction of tubing in raceway (from pt to pump)
  5. water test heat exchanger&cardioplegia system
  6. flush circuit with 100% CO2 gas
  7. clamps should be placed to direct CO2 through all CPB circuit
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6
Q

why is it important to flush circuit with CPB

A
  • to remove nitrogen in circuit
  • aids in arterial filter priming
  • helps de-air membrane oxygenator
  • facilitates gas removal from circuit while priming
  • inhibits bacterial growth incase of contamination
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7
Q

overview of circuit priming

A
  • balanced electrolyte solutions that are added through cardiotomy or venous reservoir
  • recirculate through prebypass filter
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8
Q

why is a prebypass filter helpful

A
  • 0.2 - 5 um pore size
  • removes small debris
  • must be removed prior to blood products added to prime or before CPB initiation
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9
Q

what does recirculation help

A
  • allows circuit to be “stressed” @ high flows & pressure than expected on CPB to ensure circuit integrity
  • allows for adjustments to the perfusate
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10
Q

roller pump occlusion

A
  • verify tubing size selection

- fluid should drop at a rate of 1 inch/min

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11
Q

centrifugal pump

A

-flow probe required: must be calibrated and verify inlet and out let connections

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12
Q

sucker and vent pumps

A
  • only roller pumps
  • suckers suck
  • over occlusion may lead to hemolysis
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13
Q

what is important to remember when positioning pump and arrangement of lines

A
  • pump should be placed to minimize tube lengths which will help decrease priming volume and hemodilution
  • clearly marked for identification
  • venous line should be on top of arterial line to aid in floating air locks
  • sufficient tubing lengths should be used to allow for component changeout and hand cranking
  • sucker should be checked with fluid to ensure they suck
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14
Q

what cannulation should be used on 1st time CABG or AVR

A

typically central cannulation for both arterial and venous

  • Central aortic cannulas (18-24 French)
  • central venous cannula (cavoatrial 29/29, 29/37, 32/40, 36/46)
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15
Q

what cannulation should be used on mitral valve

A

bicaval venous cannulation (entering through the right side of heart) SVC, IVC
if IVC cannulation is femoral, a venous Y tubing is needed to connect the SVC cannula

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16
Q

what type of cannulation should be used on aortic aneurysm cases

A

many require “y”ing the aortic arterial

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17
Q

steps of initiation CPB

A
  • after heparin administered, verify pt is adequately anticoagulated (THI 350 sec)
  • close all shunts
  • after arterial line insertion, run up arterial line to make free air connection
  • checkin line pressure for pulsatility
  • visualization of arterial cannula by TEE
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18
Q

to avoid exsanguination of pt in pump malfunction what should you do

A

start flow in systemic pump before releasing venous line clamp

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19
Q

flow rates on CPB

A

adult: 2.2 - 2.4 for 50-65 mL/kg during normothermia
peds: 2.5-3.0 ccl (100-150cc/kg/min)

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20
Q

gas flow rates

A

0.5-1.0:1 gas to blood ratio at normothermia

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21
Q

what does positive relief valve in cardiotomy prevent

A

over pressurization of hard shell cardiotomy

22
Q

what is important about placement of vent or retrograde catheter insertion

A

heart should be full of blood to prevent air embolism during vent or retrograde catheter insertion

23
Q

what causes high arterial line pressure

A

cannula against aortic wall
cross clamp too close to cannula
cannula too small
SVR too high

24
Q

why is temperature measured?

A
  • measured during cooling to ensure organs venerable to potential hypo perfusion benefit
  • brain most vulnerable
  • venous temp is best estimate of average body temp
25
Q

what is the best way to take brain temperature

A

nasopharyngeal temperature

26
Q

what is the relationship between temperature and gas solubility

A
  • inverse relationship

- dissolved gases come out of solution of fluid if warmed which results in gaseous micro emboli

27
Q

what should the temp radiant from heat exchanger to the venous blood be

A

no more than 8-10 C during warming

28
Q

what temperature does blood denature at

A

42 degrees C

-H/C temp may = 41

29
Q

during cooling, what temperature gradient should be maintained in arterial blood and pt temp

A

8-10 degrees C

30
Q

“table UP, head DOWN”

A

cross clamp is being removed
flows down then turn up
turn vent on immediately

31
Q

cardioplegia solutions

A

modified del Nido: 40 mEq/L potassium chloride, given 4:1 (blood:cpg)

Del Nido: 26 mEq/L potassium, given 1:4 (blood:cpg)

buck berg solution: given 4:1 (blood:cpg)

32
Q

terminating CPB

A
  • verify anesthesia is ventilating the pt
  • nasopharyngeal temp = 36.5 C
  • pacing wires are in place and tested
  • partially clamp venous line (fill the heart to see ejection)
33
Q

off CPB

A
  1. prepare to transfer volume when instructed
  2. check arterial cannula for any residual air bubbles that may have come out of the heart since coming off CPB
  3. turn sucker/vents off if fibrin glue or protamine used
  4. when protamine given too rapidly, cause hemodynamic instability
  5. monitor pt’s systolic, diastolic, and CVP pressure
  6. pay attention to volume remaining in reservoir
  7. monitor % of protamine given
34
Q

what should be done for emergency CPB

A
  1. pump plugged in and powered on
  2. gas lines connected
  3. AV loop primes and are completely
  4. 10,000 units of heparin in pump
  5. hand off AV loop
    6.have femoral access kit available
  6. turn sweep (1//2 full flow)
    8 communicate w/ surge and anesthesiologist as to needs
35
Q

what helps to prevent drainage of reservoir and distention

A

servo-regulated

36
Q

For a redo CABG, Redo AVR, what cannulation should be used?

A
  • aortic cannulation often femoral: at least femoral wire in place before sawing chest
  • venous cannulation ofter femoral: at least femoral wire inserted into SVC before sawing chest
37
Q

what should all redoes have set up and ready to go?

A

vacuum assist set up

38
Q

femoral ventilation using a 1/2” venous line requires what kind of step down

A

3/8”-1/2” tubing step down

39
Q

all venous cannulas what size connectors

A

3/8 connectors

  • 1/2 venous lines will need to be stepped down
  • if 3/8” venous line, need no adaptation
40
Q

why do you activate the systemic pump first when initiating bypass?

A

to avoid exsanguinating in the event of a malfunction of the CPB systemic pump

41
Q

after you activate the systemic bump during initiation of bypass, what comes next?

A
  • unclamp venous line
  • pump head ON (1600-1800 on centrifugal)
  • unclamp arterial line or turn on roller arterial pump
  • integrated ALF purge line open
  • check arterial line pressure (on monitor)
  • sweep gas ON (staff specific)
  • safety devices ON
  • vaccum ON (case specific)
42
Q

in order to turn vacuum on, what must you have first?

A

forward flow before vacuum is initiated

43
Q

if you are using vacuum assist monitor, what pressure do you not exceed?

A

100mmHg

44
Q

what can high arterial line pressure case

A

aortic dissection

45
Q

how can you detect aortic dissection

A
  • seen by huge drop in arterial line pressure after the initial increase
  • blood pressure drops
  • volume loss
46
Q

when should you do your first chart entry

A

-10 minutes after on bypass
or
-MAP reaches 50 mmHg (surgeon specific)

47
Q

during the case, what should you chart regarding cooling and rewarming

A

time started to cool and desired target temperature

time started to rewarm

48
Q

what should you chart and how often?

A
  • entries every 5-10 minutes (unless major changes)
  • blood gases every 15-20 minutes (unless correction needed)
  • ACTs every 30 minute (unless below anesthesia desired level and/or added Heparin)
  • cross clamp on and off
  • CPG time, given, amount, temperature, route delivered
49
Q

what should you be prepared for when the cross clamp is to be applied

A

go down on flows for cross clamp to be applied

50
Q

what should you do once cross clamp is on

A

back to full flow once clamp is ON

-start giving cog once cross clam is applied

51
Q

when coming off of CPB, what should you make sure you have?

A

have heparin ready in case you need to go back on CPB due to hemodynamic instability

Conduct of Pulmonary Bypass (2 decks)

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